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If Presentation Asc

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  • 30 months, 59 consecutive patients treated surgically forintestinal failure at St Mark’s Hospital, London, UKOne of two intestinal failure units in the UK. Surgical team associated with dedicated IF unit run primarily by gastroenterologists. Support from specialist nursing staff, stomal therapists, dieticians, social-workers, pharmacist. Weekly team meetings including all disciplines. Well developed infrastructure to manage long term home TPN patients.
  • Aetiology of intestinal failure in the 59 patients studied
  • Aetiology of short bowel syndrome. Crohn’s patients developed short bowel due to multiple previous small bowel resections.
  • Breakdown of aetiologies of enterocutaneous fistulation in our series.  Postoperative27 Emergency 22 Diverticulosis8Mesenteric ischaemia 5 Adhesions4 Ulcerative colitis3Sigmoid volvulus 1 Colonic bleeding 1   Elective5  Endometriosis1Nissenfundoplication 1Colorectal malignancy1Loop ileostomy 1Hysterectomy1 Crohn’s disease13 (primary fistulation, not iatrogenic)Trauma 2 (penetrating trauma)
  • Complex enterocutaneous fistula following laparostomy.
  • Time to definitive surgery = time from last operation to time of first definitive surgery at St Mark’s Hospital
  • All results quoted as median + rangeNumber of operations = at St Mark’s HospitalAbdominal wall defect = unable to achieve fascial closure (all 9 ECF patients with prevlaparostomy). Abdominal wall reconstruction with inlay absorbable mesh.
  • Recurrent enterocutaneous fistulae 2 healed with conservative management2 required re-operation with success1 re-operation abandoned => persisting ECFVentral herniae – 11/12 were ECF patientsPost-op sepsis (severe)3 pulmonary3 line related

If Presentation Asc If Presentation Asc Presentation Transcript

  • “Intestinal failure results from obstruction, dysmotility, surgical resection, congenital defect, or disease-associated loss of absorption and is characterized by the inability to maintain protein-energy, fluid, electrolyte, or micronutrient balance.” O’Keefe SJD, Buchman AL, Fishbein TM, Jeejeebhoy KN, Jeppesen PB, Shaffer J. Short Bowel Syndrome and Intestinal Failure: Consensus Definitions and Overview. Clin Gastroenterol Hepatol 2006; 4: 6-10.
  • Retrospective review of single-surgeon results at a UK National Intestinal Failure Centre July 2005 – December 2007
  •  59 patients  35 male  Median age 47 yrs  88 surgical interventions  Median follow up 268 days
  • Short bowel syndrome 15 (25.5%) Enterocutaneous Fistula 42 (71%) Internal fistula (Crohn’s disease) 2 (3.5%)
  • Mesenteric Ischaemia 9 Thrombophilia 3 Vasculopathy 3 Cocaine 2 Trauma 1 Volvulus 3 Crohn’s disease 3
  • Post-operative 27 (64%) Emergency 22 Elective 5 Crohn’s disease 13 (31%) Trauma 2 (5%)
  • Existing stoma 34 (58%) Requiring TPN 41 (70%) Prior operations 4 (1 - 14) Time to definitive 365 days (25 - 3,534) surgery
  • No. of operations 1 (1 - 4) Post-op stay 16 days (1-115) ICU postoperatively 6 Off TPN post-op 23 (56%) Permanent stomas 17 (29%) Abdominal wall defect 9 (15%)
  • Recurrent fistulae 5 (8.5%) Ventral hernia 12 (20%) Post-op sepsis 6 30-day inpatient mortality 0% Death during follow-up 2 (3.4%)
  •  TPN dependence reduced by 56%  Permanent stoma rate reduced by 50%  Median residual small bowel length only predictor of post-op TPN requirement Patients off TPN = 150cm (12 - 400) Patients on TPN = 75cm (5 – 295) p=0.036
  • Colon in continuity & Crohn’s disease Not significant predictors of TPN requirement post-operatively
  •  Surgical management of IF patients is safe in setting of dedicated, high volume unit  Benefits seen in reduced TPN dependence & permanent stoma rates
  •  Multidisciplinary approach essential  Pre-operative nutritional optimisation & control of sepsis  Defer definitive surgery at least 6 months  Abdominal wall reconstruction a challenge